Download Intrathecal Administration of Medications

WOMEN AND NEWBORN HEALTH SERVICE
King Edward Memorial Hospital
CLINICAL GUIDELINES
SECTION C: GYNAECOLOGY GUIDELINES
14 PALLIATIVE CARE
14.2 PAIN CONTROL IN PALLIATIVE CARE
14.2.4 INTRATHECAL ADMINISTRATION OF MEDICATIONS
BACKGROUND
Intrathecal analgesia is used for pain relief when other methods are either insufficient, or produce
excessive adverse effects. The technique involves the insertion of a catheter that is used to give pain
relieving drugs into the intrathecal space. The intrathecal space contains the cerebrospinal fluid and
the spinal cord. When pain relieving drugs are given in this way they produce pain relief by spreading
into the spinal cord or the nearby nerves to block the transmission of pain impulses.
KEY POINTS1
1. If good analgesia can be achieved with minimal side effects and risks using alternative route,
there is little evidence for improved outcomes with the intrathecal route.
2. The long term intrathecal administration of drugs is an established method of pain
management in a small carefully selected subgroup of patients.
3. Medications may be administered directly into the intrathecal space, as single or repeated
injections or by continuous infusion.
4. This form of therapy is generally reserved for patients in whom pain or spasticity is not
adequately controlled by less invasive methods and who meet certain criteria.
5. Intrathecal drug administration can result in significant undesirable side effects, and has the
possibility of morbidity and mortality.
6. Effective management of intrathecal therapy requires appropriate patient selection. Education
of the patients increases their understanding of the potential benefits, risks and their
responsibilities.
7. Prior to the consideration of a trial of intrathecal drug therapy, the response to appropriate trials
of oral and parenteral therapies should be assessed.
8. Treatment requires regular assessment and documentation of efficacy, tailoring therapy to the
individual.
9. Treatment requires ongoing assessment of the patient’s pain, function and quality of life.
10. Opioids and local anaesthetics are the most frequently utilised agents for long term intrathecal
therapy.
11. Failure to respond to an intrathecal trial or need for a rapidly increasing dose may indicate pain
that is poorly responsive to opioids.
DPMS
Ref: 8527
All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual
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12. Inadequate analgesia may result in dose escalation of opioid over time. It is important to
consider the many factors which may result in inadequate analgesia including:
i.
ii.
iii.
iv.
v.
vi.
vii.
Development of tolerance
Progression of the underlying disease
Emergence of a new source of pain
Development of opioid induced hyperalgesia
Distress
Social reinforcers
Pain which is not opioid responsive.
13. Both physician and the patient should be aware of current data relating to safety and potential
neurotoxicity of the proposed intrathecal medications. Toxicological studies to date suggest no
long term adverse effects of baclofen, morphine, bupivacaine or clonidine.
14. The procedure is performed with strict septic technique whatever the setting.
15.
16. Consult the managing pain or Palliative Care Specialist for advice about changing the:
• Drug combination.
• Rate of delivery
• Bolus doses
• Lockout time
17. The intrathecal infusion must be prescribed with clear instructions and boundary rates
18. The infusion rate must remain within the prescribed limit.
19. The intrathecal infusion and rate must only be altered by a registered nurse / midwife that has
undergone suitable training in the management of epidural / intrathecal infusions.
20. The intrathecal line and syringe will be labelled as per clinical guideline A 4.14 Labelling of
Injectable Medicines and Fluids
INDICATIONS
•
Severe uncontrolled pain despite appropriate prior attempts to control the pain using
conventional palliative care analgesics.
•
Unacceptable side effects from systemic opioids.
•
Urgent pain control near the end of life when time is not available to titrate analgesics in a
standard fashion.
CONTRAINDICATIONS
ABSOLUTE
•
Patient refusal.
RELATIVE
•
Confused patient unable to give informed consent.
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•
•
•
•
Infection near the site of line placement or untreated septicaemia
Anticoagulated patients with bleeding dyscrasia
Raised intracranial pressure
Infection risk.
PRACTICAL DIFFICULTIES
•
•
Previous spinal surgery / deformity
Severe obesity
ADJUSTING THE EXISTING DRUG REGIME PRIOR TO THE PROCEDURE
•
•
•
•
Long acting opioids should be converted to four hourly preparations 12-24 hours prior to the
procedure.
Fentanyl patches should be removed 24-48 hours prior to the procedure, changing to an
immediate release opioid.
On the morning of insertion, reduce the opioid by 30-50%,but ensure an immediate release
opioid is available for breakthrough pain
Prophylactic antibiotics should be prescribed to be given on the day of the procedure.
PROCEDURE FOR INSERTION AND COMMENCEMENT OF AN INFUSION.
1. Resuscitation equipment must be available during insertion.
2. Ensure intravenous access is present prior to the procedure.
3. Perform baseline observations prior to insertion.
4. Prophylactic antibiotics are given prior to the procedure.
5. Following insertion and administration of the initial dose the following observations shall be
recorded – pulse, respiratory rate, oxygen saturation rate, BP, sensory level –cold
discrimination with ice, motor power in the upper and lower limbs and pain
• Every 15 minutes for the first hour
• Every 30 minutes hourly for the next 2 hours
• Respiratory rate, sedation and pain scores must be recorded hourly until at least 24
hours post insertion or longer if the patient’s observations are unstable.
6. Observations after any rate or content change
Every 30 minutes for an hour.
4 hourly for 24 hours.
7. Daily
i.
Temperature, blood pressure, respiratory rate,oxygen saturation rate, level of the block
for the first 7 days(sensory level to cold and upper and lower limb power)
ii.
Daily check for urine retention
iii.
Pain score when necessary: daily until stable, then when changes occur
iv.
Observe site for signs of infection / leakage
v.
The puncture sites from the tunnelling should be cleaned and redressed until they are
healed for the first week.
vi.
Observe for signs suggestive of CSF infection
vii.
Ensure the dressing is intact, including the security of the line between the exit and
extension.
viii.
The infusion pump should be checked four hourly.
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8. After 7 days, the dressing over the exit site should be changed weekly using an aseptic
technique.
9. The distal filter should be changed at 60 days.
10. If there is a leak of CSF or infusion fluid at either side of the compression hub or at the
proximal filter, then serious consideration should be given to removing the line. The
anaesthetist and palliative care team should be involved in the decision.
POSSIBLE PROBLEMS
When assessing all problems, the most appropriate course of action for the individual always
needs to be considered in the context of
o Their disease status.
o Potential prognosis
o Risk / benefits of continuing spinal line analgesia
LEAKING CATHETER SITE / MOVEMENT OF THE LINE
•
•
Can occur post procedure at the primary insertion site for a few days. Apply compression
bandaging to the area. Leakage may also signify a migration of the catheter, therefore review
placement including any recent change in pain control. Concerns about migration should be
report to the anaesthetist urgently.
Leakage at the exit site – check the integrity of the compression hub / spinal catheter junction.
It may need to be tightened. If it has become disconnected, removal of the spinal line must be
considered. Although it may be appropriate to leave in situ of the clinical situation dictates this.
CRACKED FILTERS
•
Replace if damaged using a full aseptic technique. If both filters are disconnected the situation
needs urgent discussion with medical staff and the anaesthetist. Serious consideration should
be given to whether the line should be removed but a risk benefit analysis needs to be
considered depending on the clinical situation. If the line is removed the tip should be sent off
to microbiology for assessment of infection.
INFECTION
•
•
Infection can occur locally around the exit site or within the CSF, causing meningitis. Signs and
symptoms of infection are as follows
o Raised temperature
o Redness,swelling , heat, discharge at the exit site and possible palpable subcutaneous
spinal line track.
o Photophobia
o Neck stiffness
o Headache
o Drowsiness
o Increased pain or possible increased analgesia due to increased absorption with
meningeal inflammation.
o General non specific deterioration.
If infection is suspected arrange urgent medical review.
BACK PAIN
•
Any complaint of persistent or increasing back pain particularly if it is referred to the legs must
be taken seriously. Possible causes include spinal cord compression, haematoma or abscess
formation.
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•
Arrange for urgent medical review. Discontinue the infusion until the review is completed.
THE LINE FALLS OUT
•
Ensure adequate systemic analgesia is available while the situation is being reviewed.
HEADACHE
•
•
•
•
Severe frontal headaches may indicate a leak in the cerebrospinal fluid, but usually occurs in
the early post insertion period.
Request medical review
It may be relieved by simple analgesia, bed rest and lying flat.
If it persists, other potential causes such as meningitis must be excluded.
INADEQUATE ANALGESIA
•
•
•
Review that the infusion is working correctly.
Ensure that adequate breakthrough analgesia is provided.
Request medical review
URINARY RETENTION
•
•
•
•
This can be due to increased tone of the sphincter at the exit of the bladder caused by either
opiate and / or local anaesthetic.
Request medical review.
A short or long term urinary catheter may be required.
A sudden change in bladder control not associated with spinal drug increases may indicate a
spinal cord compression
REFERENCES ( STANDARDS)
1. Royal Cornwall Hospitals. Nursing Guidelines for the Care of a Patients with an Intrathecal Infusion.2012
2. NHS UK. 2012. Palliative and End of Life Care Guidelines. Available at http://www.cancernorth.nhs.uk
National Standards – 1 Clinical Care
Legislation - Nil
Related Policies – Section 14 Palliative Care
Other related documents – A 4.14 Labelling Of Injectable Medicines and Fluids
P Administration of Schedule 8 Controlled Medications
RESPONSIBILITY
Palliative Care Consultants
Policy Sponsor
May 205
Initial Endorsement
May 2014
Last Reviewed
Last Amended
May 2017
Review date
Do not keep printed versions of guidelines as currency of information cannot be guaranteed.
Access the current version from the WNHS website
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